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SAN JOAQUIN C UNTY ENVIRONMENTAL HEALTH DIVISION <br /> MASTE E RECORD IINFORIVLATION FORM(EH 00 69) <br /> few EH Program at Existing Facility <br /> ❑New EHDPro and New Facility <br /> acili ID .�,7 Program Record ED 110k ���Sl� <br /> Facility Address 6 C-- <br /> (Please Check the appropriate description and specify size•number of units and pert[ ent information.) <br /> FOOD PROGRAM(1600) <br /> C3 Restaurant: Seating Capa iry Square Footage <br /> Food Handlers Course required: Yes C1 No 11 <br /> ❑ Commissary C1 Dry storageonly C1 with Food Preparation ❑Vending Machines-Number of Units <br /> ❑ Retail Market---Square foo age ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br /> Vehicle Type Color <br /> ❑ Mobile Food Vehicle---M e Sticker# <br /> Registration# License# <br /> Vehicle Type Color <br /> (:1 iVlobile Food Prep Unit--Mae Sticker# <br /> Registration# License# <br /> to ❑ Ice Plant <br /> ❑ Temporary Food Facility— Dates of operation from ❑ Produce Stand <br /> ❑ Special Event - Dates of operation from to <br /> DAIRY PROGRAM (2000) <br /> C1 Milk Dispenser—Number of Containers in Multi-Head Unit <br /> ❑ Grade A Dairy C1 Grade B Dairy <br /> HAZARDOUS to Facility Surc arge(2399) <br /> US WASTE P OGRAM(2200) <br /> cUPA ilzardous Wast thorized(CA) ❑ Conditionally Exempt(CE) <br /> Generator---------------- <br /> Tons Generated Per Year <br /> rier', <br /> dPermitting Facility ❑ Conditionally Au <br /> ❑ Permit-By-Rule Fixed Unit ❑ Permit-By-Rule Household Hazardous Waste <br /> ❑ ABOVEGROUND ST RAGE TANK FACILITY(AST)(2390)—Number of AST <br /> UNDERGROUND STOR. GE TANK(UST)PROGRAM(2300)Use UST A and B forms <br /> HOUSING PROGRAM(2400) <br /> ❑ Jail or Exempt Institution Number of Units <br /> C] HoteUiviotel-------Number oUnits <br /> Employee Housing(2700) Use E to ee HousinglLahor Cam Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> e ❑ UIC Site <br /> ElEnvironmental Assessment ❑ UST-CAP Site C1 Local HW Cleanup Site ❑ NPUSEP Cleanup Sit <br /> ❑ Abandoned HW Site C1 non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site C1 Water Quality Remediation Site <br /> RECREATIONAL HEALTH ROGRAM(3600) C1 Natural Bathing Area <br /> Number of pools/Spasat Facili Cl Pool ❑ Spa C1 out of Service PooUSpa <br /> VECTOR CONTROL PROGRAM(4000) ❑ Kennel <br /> ❑ Poultry Farm Maxim m number of birds <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) ❑ Permanent Cosmetics(4122) <br /> ❑ Tattooing(412 1) ❑ Body Piercing(4120) <br /> LIQUID WASTE PROGRAM 4200) Capacity Vehicle# <br /> ❑ Pumper Vehicle-Registration# License# <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets Number of Units <br /> SOLID WASTE PROGRAM( 00) ElSludge/Ash Site <br /> C3 Landfill Transfer Station ❑ Ag/Cannery Waste Site <br /> ❑ CIA Landfill Site <br /> ❑ Process/Recycle Facility <br /> ❑ Waste Tire Facility Compost Facility ❑ Farm/Ranch Cleanup Site <br /> ❑ Refuse Vehicles-Number f Units ❑ Dumpsters>20 cu yd—Number of Units <br /> MEDICAL WASTE PROG M(4500) <br /> ❑ Primary Care ❑ Ac to Care ❑ Skilled Nursing C1 Large Generator '- ❑ Smal]❑Generator 0 Limited generators <br /> PUBLIC <br /> ❑ Transfer Station ❑ Ve erinary Clinic ❑ Common Storage Facility—❑ - 10-- <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EH0069 Blue Ayplicarion Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY ANO/OR PROGRAM <br /> CONTACT PERSON <br /> Day Ph Night Ph <br /> ❑ Surcharge FEE ❑ Other FEE <br /> PROGRAM ELEMENT IK <br /> 'L' FEE u to m . 1 C L ❑ Food Handler <br /> I; <br />